| Certificate Number | 710 | | Date Issued |
| Child Given Name | |
Burns | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Jul 1883 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Fuller |
Burns | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Ohio | 32 | Father's Age |
| Mother's Surname | Burns | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 5 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper | | |